Report of the American Medical Association Interim (Virtual) Meeting

The 2021 Interim Meeting of the AMA House of Delegates (HOD) was planned for Orlando, at Disney World. But thanks to COVID, all the delegates sat in front of computers for four days, November 12–16. And yes, that is just as boring as it sounds. This is the fourth virtual meeting of the AMA. None of them have been very good. The AMA uses two different online platforms (Zoom and Lumi, if you’re interested). Last year’s Interim meeting was the first with the new system. We said then: “Nobody wants to do it again.” Yet, here we were. Everyone can speak, with some difficulty, so we can have reference committees, general sessions, and brisk debate. It turns out that the online platform works well enough, but we lose the personal interaction which really makes the AMA work.

Possibly because of the virtual format, the HOD sessions were somewhat less well-attended than previous Interim Meetings, drawing two-thirds of delegates (actually, 55% to 70%). As usual, the Interim Meeting was focused on urgent matters, particularly those dealing with legislation. Only some of the resolutions offered were considered at the meeting. The Resolutions Committee has been responsible for screening. There was debate over whether this process should be made permanent, and the question was referred to the Board of Trustees (BOT).

Gerry Harmon, MD, AMA president, addressed the meeting. He spoke a lot about the pandemic, which has killed more than 750,000 Americans. And the vaccination campaign, which has fallen short of our hopes. He compared the AMA to an army, against COVID, against injustice, and against “unresponsive bureaucracy.” Dr. Harmon is a retired Major General (Air Force), so his military metaphor seems natural. He emphasized that the AMA promotes equity and racial justice both within the AMA and in the health care system. Systemic racism, he said, continues to harm “individuals and communities.” More broadly, he highlighted three key battles for the coming year. First, Medicare payment reform, with prevention of payment cuts of 10% in 2023. Second, prior authorization reform. And third, promoting health equity to create a health care system which works for all patients.

James Madara, MD, Executive Vice President, spoke about trust. Trust in America’s institutions has been challenged over the past two years, but trust in physicians remains strong. As well, the AMA remains one of the most trusted national institutions. Shifting the meaning, he described the AMA as a public trust. We serve the public by supporting physicians, and through them the health care system and to society in general. He cited several AMA efforts, such as promotion of clinical ethics, advocacy for health equity, and innovations through Health2047, an arm of the AMA. AMA strategy continues to be based on equity, advocacy, and innovation. Dr. Madara noted: “The AMA is committed to creating a health system that’s accessible, efficient, and equitable. To get there we need an environment that supports physicians … one that allows doctors to be doctors rather than scribes and box checkers.”

Indeed, health equity was a major theme of the meeting. A number of reports and resolutions focused on the issue of health equity. A separate program on health equity was held for the delegates and alternates on November 14. Speakers generally deplored inequities in the health care system. But just how to make things better remains unclear. There are 29 million still uninsured in the U.S. AMA trustee David Aizuss noted that we can afford to eliminate this “coverage gap,” and that the AMA will continue to work for universal health care.

There was a major effort to address inequities in maternal health care. A joint report from the Councils on Medical Service (CMS) and Science and Public Health focused on eliminating inequities in maternal health. Resolution #701 advocated that all patients receive care for 12 months post-partum. The AMA will advocate for 12 months of pregnancy-related health care costs for all individuals, regardless of legal status, to be paid through Medicaid and CHIP programs. Further, pregnancy should be considered a qualifying event for getting insurance coverage. If enacted by Congress, this would be a major expansion of government-based health insurance. CMS report #4 advocated better financing of home and community-based health services. And CMS report #2 called for better information availability on lower cost prescription options.

Educating and maintaining the physician work force is a primary concern of the AMA. The Council of Medical Education (CME) report #1 dealt with principles of assessing competency in late career physicians. There was considerable concern that any physician should be entitled to due process protections in competency assessment. CME report #2 advocated the removal of barriers to medical education by individuals with disabilities. CME report #3 dealt with the chronic problem of rural physician work force disparities. The AMA will recommend that rural program tracks be added to existing training programs, among other initiatives. Discussion introduced the concept of “structural urbanism,” said to be a systemic bias against rural areas in federal payment and other policies. CME report #4 assessed the influence of medical school debt on career choice. Perhaps surprisingly, the report concluded that there was relatively little influence, but acknowledged that excessive debt continues to haunt medical trainees. Studies will continue and the AMA will continue to support increased participation in the Public Service Loan Forgiveness Program.

Resolutions from the Medical Student Section included support for Puerto Rican medical schools and graduates (resolution #309) and support for students during the phase-out of 3-digit scoring of the USMLE Step 1 (resolution #301). Resolution #309 called for protecting access of medical students and residents to abortion education and training, making modifications to the current policy which supports such training.

There was a move to establish an employed physician section in the AMA to deal with the particular problems of physicians as salaried workers (resolution #615). While the idea of a separate section was not accepted, it was clear that the Board of Trustees (BOT) should address problems in the employed sector. As the dominance of hospital systems becomes greater, corporate governance is replacing hospital board and medical staff governance. BOT Opinion 11.2.1 lays out principles for physician responsibility in large systems. In fact, employed physicians have now become the majority, and their concerns are the concerns of the AMA.

The HOD considered a number of current political issues. BOT report #2 advocated police reforms, and that they should be evidence-based. The report generally took a moderate approach. A number of the delegates disagreed with moderation. There was acrimonious debate over qualified immunity, which protects police officers from civil suits. Some feel it should be abolished entirely. In the end, the AMA position remains that there is little evidence that abolishing qualified immunity would improve public safety. The HOD adopted guidelines for voting in national, state, and local elections, on the grounds that voting is a health issue in a time of communicable diseases (resolution #18). Oddly, this resolution mentioned no pandemic-specific measures, and was solely concerned with access to voting. More connected to medical issues, the AMA should advocate Medicare negotiation on drug prices, something which is currently in Congress.

In the COVID pandemic, public health has become a political issue. The HOD adopted policy strengthening public health infrastructure, and opposing placing limits on public health authorities. Somewhat related to this were resolutions #411 and #412 to promote the dissemination of misinformation. A related resolution (#207) called for limiting the authority of non-physician practitioners to provide medical exemptions to vaccination. There was general agreement by speakers that physicians should be more active in speaking out on public health issues, especially including vaccinations, and on “helping science get heard.”

Much less controversial was a resolution (#506) to strengthen standards to protect workers from heat injuries. Originally formulated to protect outdoor workers, this was expanded by the HOD to apply to all workers. Federal standards in this area are vague, and the AMA will now work to promote more precise standards to protect workers.

Council on Science and Public Health report #3 dealt with the effects of traumatic brain injury on driving. Research should be encouraged on just how far a patient needs to recover before he or she should be able to resume driving a car, which may be required for the patient to return to gainful employment. It was noted that many of the same considerations apply to firearm use, although of course this is only occasionally related to continued employment.

Of particular interest to dermatologists was a resolution (#505) to improve the teaching of dermatology by advocating including pictures of patients with a wide variety of skin tones. With our patient populations becoming steadily more diverse in skin color, this would both promote health equity and improve the diagnosis of skin lesions.

From the Council on Ethical and Judicial Affairs (CEJA) report #1 dealt with the issue of short-term medical service trips. While these are increasingly being carried out, there is concern that they may fail to benefit the host countries. Scarce resources may be diverted to support such trips. Some even term such trips as a form of “medical colonialism,” a description which is certainly derogatory, but can be a bit hard to follow. Yet, these trips may result in better host country education, and can provide benefits to the host county medical systems. The report was sent back to CEJA for reconsideration, reflecting the many difficult issues involved.

Several physicians from Missouri serve in leadership roles. David Barbe, MD, represents the AMA on the world stage as Immediate Past President of the World Medical Association. Edmond Cabbabe, MD, serves as vice chair of the Council for Long Range Planning and Development. Elie Azrak, MD, serves on the board of AMPAC, the AMA Political Action Committee. Jerry Kennett, MD, is on the AMA Foundation board. Marc Mendelsohn, MD, is on the board of the Young Physicians Section. Gary Gaddis, MD, is Immediate Past Chair of the Academic Physicians Section. Sue Ann Greco is the Immediate Past President of the AMA Alliance. Charles Van Way III, MD, is on the steering committee of OSMAP, the Organization of State Medical Association Presidents.

Your AMA delegation would very much like to hear from AMA members throughout Missouri about all of the issues discussed at the meeting. For further information, the business of the meeting is available on the AMA website. Highlights are at: https://www.am-aassn.org/house-delegates/special-meeting/highlights-november-2021-ama-special-meeting. All of the reports and details are at: https://www.ama-assn.org/house-delegates/special-meeting/business-november-2021-special-meeting-ama-house-delegates.

The Annual Meeting of the HOD is scheduled to take place in Chicago, June 12–16, 2022. We all hope that it will take place as planned, and in person. Meanwhile, the AMA continues to advocate for physicians and their patients at the national level.